Endoscopy-Assisted Laparoscopic versus Laparoscopic Surgery for Gastrointestinal Stromal Tumor and the Impact on Patients' Coagulation, Surgical Condition, and Complications

Objective To assess the clinical efficiency of endoscopy-assisted laparoscopic versus laparoscopic surgery for gastrointestinal stromal tumors and the impact on patients' coagulation, surgical condition, and complications. Methods Between November 2016 and May 2020, 126 eligible patients diagnosed with gastrointestinal stromal tumor (GIST) in our institution were recruited. They were concurrently randomly assigned at a ratio of 1 : 1 to receive either laparoscopic gastrectomy (reference group) or endoscopy-assisted laparoscopic gastrectomy (research group). The two groups were compared in terms of patients' coagulation function, surgical conditions, and complications. Results The two groups had similar preoperative coagulation indices and the postoperative levels of activated partial thromboplastin time (APTT) and thromboplastin time (TT) (P > 0.05). Compared with the reference group, the research group showed lower PT levels (10.48 ± 0.68 vs. 11.97 ± 0.46) and higher FIB levels (0.67 ± 0.11 vs. 0.29 ± 0.07) (P < 0.05). Compared with the reference group, the study group had shorter operative time (81.21 ± 10.24 min versus 98.98 ± 15.31 min), shorter surgical incision (3.63 ± 1.12 cm versus 5.01 ± 1.14 cm), and less intraoperative bleeding (18.74 ± 6.98 ml versus 58.69 ± 15.87 ml) (P < 0.05). A markedly shorter length of hospital stay, time to the first postoperative exhaustion, and duration of drainage tube and gastric tube dwelling were observed in the research group versus the reference group (P < 0.05). The study group presented higher nutritional levels of patients at 3 days after surgery and a lower incidence of complication. Conclusion Endoscopy-assisted laparoscopic treatment shows significant improvements in the efficiency of minimally invasive surgery and ensures a better prognosis and quality of life of patients with a good safety profile, so it is worthy of clinical application.


Introduction
Gastrointestinal stromal tumor (GIST) is a common malignancy that originates from the mesenchymal tissue of the gastrointestinal tract and accounts for most of the mesenchymal tumors in the gastrointestinal tract, with a high prevalence. e absence of specific clinical symptoms and the relatively insidious site of the lesion prevent effective diagnosis of the patient in the early stage [1,2]. With the advancement of medical technology [3], laparoscopic gastrectomy is considered the mainstay for the treatment of GIST. It is a newly developed minimally invasive method with benefits such as small incisions, minimal scarring, reduced pain, fewer postoperative adhesions, and shorter hospital stays [4]. However, disadvantages such as incomplete surgical field of view and the complicated tumor resection due to the small size or insidiousness of tumors compromise the success of laparoscopic surgery, which desires improvements in clinical efficiency and safety [5,6]. Endoscopy is a sophisticated imaging technology that provides a pictorial accuracy to allow the diagnosis of tumors with extremely small size [7]. Endoscopy-assisted laparoscopy avoids surgical blind spots to a greater extent to achieve better efficacy, taking into account the tumor size, location, and underlying disease in treatment regimen designs [8]. Previous research has reported significant enrichment in patients' postoperative recovery of endoscopyassisted laparoscopic gastrectomy for GIST [9]. Here, endoscopy-assisted laparoscopic gastrectomy was adopted for the treatment of GIST resection, to provide a safer and more efficient treatment protocol. e results are as follows.  Figure 1).

Inclusion and Exclusion Criteria.
Inclusion criteria: all eligible patients were diagnosed with GIST after examination; without recent use of other drugs; and provided written informed consent. is study was approved by the ethics committee of our hospital.
Exclusion criteria: patients with cardiovascular and cerebrovascular complications; with contraindications related to surgery; and with tumor metastases.

Methods.
After preoperative examinations, patients in the reference group were given laparoscopic gastrectomy. Patients in the study group receive endoscopy-assisted laparoscopic gastrectomy: with the patient in a supine position, endotracheal intubation with intravenous compound general anesthesia was performed, followed by trocar puncture and pneumoperitoneum establishment with carbon dioxide, with the pneumoperitoneum pressure maintained at 12∼15 mmHg. e endoscope was properly placed, and the patient's lesion was accurately localized again by endoscopy-assisted laparoscopy according to the patient's preoperative examinations, followed by laparoscopic gastrointestinal tumor resection under the guidance of endoscopy. After surgery, specimens of the patient's lesions were collected to obtain the pathological diagnosis results. e patient was given basic postoperative treatment such as gastrointestinal decompression, nutritional support, and anti-infection.

Outcome.
Before and after surgery, 1.8 ml venous blood was collected from the eligible patients for coagulation indexes determination, including prothrombin time (PT), activated partial thromboplastin time (APTT), thromboplastin time (TT), and fibrinogen (FIB). Intraoperatively, the operative time, surgical incision, and intraoperative bleeding were recorded for both groups to compare and analyze the patients' intraoperative conditions. e length of hospital stay, time to the first postoperative exhaustion, and duration of drainage tube and gastric tube dwelling of the two groups were recorded and compared. e levels of prealbumin (PA), transferrin (TRF), and albumin (ALB) in the two groups were recorded and monitored 3 days after surgery to assess the nutritional status of the two groups of patients. Complications including postoperative gastric fistula, abdominal infection, incisional infection, and gastrointestinal dysfunction were monitored and recorded to calculate the incidence of complications for the two groups.

Statistical
Analysis. GraphPad Prism 8 software was used for image rendering, and SPSS22.0 software was used for data analyses. e count data were expressed as [n(%)] and subject to chi-square test, and the measurement data were represented by (x ± s) and processed by the t-test. Differences were considered statistically significant at P < 0.05.

Coagulation Function.
e two groups had similar preoperative coagulation levels of PT, APTT, TT, and FIB (P > 0.05). After surgery, there was no significant difference in APTT and TT levels between the two groups (P > 0.05).

Discussion
Gastrointestinal stromal tumor (GIST) is a tumor of the mesenchymal tissue of the gastrointestinal tract with a high incidence of about 0.1-0.2 per 10,000 people [10]. e disease may be asymptomatic, and potential symptoms include abdominal pain, distension, vomiting blood, black stools, and abdominal masses [11]; however, the absence of specific symptoms and the insidiousness of the lesion complicate the effective diagnosis of the disease in the early stage [12]. e deficiency in the treatment efficiency of GIST is attributable to the small size and special location of tumors despite laparoscopic surgery as the choice of treatment with curable intent [13]. Moreover, the unsatisfactory surgical field of view of laparoscopy compromises the accurate assessment of surgical complications [14,15]. e endoscopyassisted laparoscopic gastrectomy is a new minimally invasive treatment protocol for GIST patients which allows the integration of endoscopy and laparoscopy to enhance the treatment efficiency [16]. Research has shown that endoscopy-assisted laparoscopic surgery provides effective recovery for GIST patients without serious complications [17,18]. It has also been reported that such surgical protocol could minimize surgical trauma to ensure higher safety [19,20]. Results of the present study showed superior coagulation indexes in the eligible patients given endoscopyassisted laparoscopic gastrectomy versus laparoscopic gastrectomy alone, which indicates the benefits of the combined method in the protection and enhancement of coagulation functions. Besides, the combined protocol provides better intraoperative conditions for the patients, which may be attributed to the precision of tumor location and a small incision to abate intraoperative bleeding. Furthermore, patients in the research group obtained better improvements in postoperative conditions and nutritional status, indicating that endoscopy-assisted laparoscopy facilitates postoperative recovery and mitigates the negative impact of the surgery, which, consequently, results in a lower risk of complications, as evidenced by the lower incidence observed in the research group versus the reference group herein.
To sum up, endoscopy-assisted laparoscopic treatment shows significant improvements in the efficiency of minimally invasive surgery and ensures a better prognosis and quality of life of patients with a good safety profile, so it is worthy of clinical application.

Data Availability
e datasets used during the present study are available from the corresponding author upon reasonable request.    Disclosure is research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Conflicts of Interest
e authors declare that they have no conflicts of interest.